By Dr Orla Tuohy, Locum Consultant Neurologist, Queen Alexandra Hospital, Portsmouth, and Southampton General Hospital
MS Specialists MasterClass 6, 2019
The Association of British Neurologists (ABN) 2015 multiple sclerosis guidelines, recommends starting eligible patients with active relapsing-remitting multiple sclerosis, on disease modifying therapy (DMT) as early as possible. As well as the increasing complexity of DMT decision-making, many of the more recently-licensed DMTs require pre-treatment screening, +/- consenting for treatment, and approval at regional multi-disciplinary meetings, which have the potential to increase the time interval between DMT selections and starting on treatment.
The aim of this project was to explore, in our regional patient cohort attending MS clinics in the Wessex neurological centre, Southampton, the time interval between DMT selection and commencement of treatment. By analysing the collected data it was hoped to identify any variability in starting times between DMTs, and to identify any areas where potential exists for service reform and improvement.
Data was collected via the local electronic patient record system, on patients attending new patient appointments in specialist multiple sclerosis clinics in the Wessex neurological centre, Southampton over the two month period from January to the end of February 2019. Patients who were eligible to start disease-modifying therapy, and in whom a decision had been made to start treatment were included in the study. Data collected included the specific disease-modifying therapy selected, and the time taken from the decision date to starting treatment. First-line injectable DMTs, interferon-beta and glatiramer acetate were considered together.
Thirty-two patients were identified who were suitable for inclusion in the study. The disease modifying therapies for these patients, and number of patients per DMT, were interferon-beta or glatiramer acetate (n=12), dimethyl fumarate (n=10), fingolimod (n=1), natalizumab (n=4), alemtuzumab (n=2), cladribine (n=2), and ocrelizumab (n=1). The mean times to start treatment were as follows: interferon-beta and glatiramer acetate (1.5 months), dimethyl fumarate (2.1 months), natalizumab (2.8 months), alemtuzumab (2 months), cladribine (2 months), and ocrelizumab (3 months).
The small sample size limited the statistical analysis, and no significant differences were observed between DMTs in starting time, e.g the p-value for the comparison of interferon-beta and glatiramer acetate, versus natalizumab was p=0.4, before correction for multiple comparisons. On review of the data there is a trend for a longer time to starting for higher efficacy DMTs, namely natalizumab and ocrelizumab versus first-line injectable DMTs.
While no statistically significant results emerged from this study of DMT starting times, a trend for a longer time to start treatment for higher efficacy infusional therapies was observed. Potential factors in this longer time from DMT selection to starting treatment, include the need for baseline blood testing e.g JCV serology for natalizumab, patient consent often requiring an additional consultant clinic appointment, and the need for MDT approval of these higher efficacy drugs. Proposed strategies to reduce the time to starting on treatment include increasing the frequency of the MS MDT, and/or establishing a virtual MDT to allow DMT approval in between scheduled MDTs, along with the introduction of nurse-led consenting which would mitigate the need for additional consultant clinic appointments prior to starting treatment.